Agreement of Release and Waiver of Liability

This form covers all classes and/or programs offered by GeriHab Physical Therapy and Wellness Please fill out the following, being sure to read and initial each paragraph.

Consent
I hereby agree to the following: That I am participating in group physical therapy classes or other programs offered by GeriHab PT and Wellness during which I receive education, information and instruction about exercise, wellness and prevention. I recognize that these group physical therapy classes and programs may require physical exertion, which may be strenuous. Although unlikely, physical injury could occur. I am fully aware of the risks and hazards involved and I agree to assume any responsibility to any injury. I will follow all instructions and modifications recommended by my Premier PT and Wellness.
Consent*
I understand that it is my responsibility to consult with a physician prior to and regarding my participation in group physical therapy classes and/or programs. I represent and warrant that I am physically able to participate in exercises classes and I have no medical condition that would prevent my full participation in these group physical therapy exercise classes and/or programs.*
Consent*
I have read and understand the Exercise Guidelines for participation in Group Exercise class*
Consent*
I agree to inform GeriHab PT and Wellness of any physical limitations, physical discomforts and/or injuries before or during fitness classes and/or programs, and I take full responsibility for nondisclosure.*
Consent*
I have read the above release waiver of liability and fully understand its contents.*
Name
First Last
Date
Date Format: MM slash DD slash YYYY
Signature

Agreement of Release and Waiver of Liability

Agreement of Release and Waiver of Liability

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